Deep Anterior Lamellar Keratoplasty (DALK) is a type of corneal transplant procedure primarily aimed at preserving the patient’s endothelial layer, which is the innermost layer of the cornea. Here’s a breakdown of its key aspects and differentiating factors:

  1. Preservation of Endothelium:
    • Unlike Full Thickness Corneal Transplant (Penetrating Keratoplasty, PK) where all layers of the cornea are replaced, DALK replaces only the anterior layers, leaving the patient’s own endothelium intact. This reduces the risk of graft rejection significantly.
  2. Origin:
    • The concept of lamellar keratoplasty has been around for over a century, but modern DALK procedures have been refined over the last few decades. The advent of newer surgical techniques and better understanding of corneal anatomy has made DALK a more viable option.
  3. Popularity:
    • DALK has gained popularity due to its lower rejection rates and better long-term outcomes when compared to PK. It’s particularly popular in cases where the endothelial layer is healthy but the anterior layers of the cornea are diseased or damaged.
  4. Technical Skill Required:
    • DALK is technically more challenging and requires skilled surgeons with expertise in corneal transplantation. This is because the procedure involves precise dissection to separate the layers of the cornea without damaging the endothelium.
  5. Recovery and Rehabilitation:
    • Post-operative recovery might be slightly longer than PK, but the lower risk of rejection and other complications make it a favourable option for eligible patients.
  6. Special Considerations:
    • Patients considering DALK should be aware that not all corneal conditions are suitable for this procedure. It’s critical to have a thorough evaluation by a corneal specialist to determine the most appropriate type of corneal transplant.
  7. Cost and Availability:
    • The cost of DALK can be higher due to the surgical skill required. Moreover, the availability of experienced surgeons and suitable donor corneas may vary geographically.

For anyone considering a DALK procedure, it’s imperative to consult with a qualified ophthalmologist to understand the risks, benefits, and whether this procedure is the right choice based on the individual’s specific condition and overall eye health.

Why I opted for DALK

Reduced Rejection Rates with DALK:

  • DALK has a significant advantage over full-thickness corneal transplants, such as Penetrating Keratoplasty (PK), when it comes to the risk of rejection. Since DALK preserves the patient’s own endothelial layer, the risk of endothelial rejection is eliminated. However, other types of rejections like subepithelial and stromal rejection can still occur, but they are typically less severe and easier to manage compared to endothelial rejection.

Comparison with Other Procedures:

  • Studies have shown that DALK has fewer cases of graft rejection compared to PK. In one comparison, the odds ratio (OR) of graft rejection was 0.28 for DALK compared to PK, indicating a significantly lower risk of rejection with DALK.

Long-term Outcomes:

  • The long-term outcomes of DALK are generally favorable due to the lower rejection rates. Moreover, in case of any rejection, medical management is often successful in reversing the rejection.

Post-Operative Care:

  • Effective post-operative care, including the use of anti-rejection eye drops (usually corticosteroids), plays a crucial role in further minimizing the risk of graft rejection.

Individual Variation:

  • It’s important to note that individual response to corneal transplants can vary, and a thorough discussion with the ophthalmologist is essential to understand the specific risks and benefits based on one’s unique eye health condition.


  • Regular follow-up appointments with the ophthalmologist will help in early detection and management of any signs of graft rejection, thus improving the overall success rate of the procedure.


  • Patients can be reassured that with the advancements in corneal transplant techniques, the incidence of graft rejection has been significantly reduced, and DALK stands as a safer option in suitable cases.

Dr Holland was Available in Cincinnati – 90 minutes from my house.

  • After extensive research and speaking with my ophthalmologist, I was introduced to Dr. Holland at Cincinnati Eye Institute – where I was able to ask him about DALK options. He confirmed I was a good candidate.

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